TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

Health Disparities and Health Equity: The Issue Is Justice

Eliminating health disparities is a Healthy People goal. Given the diverse
and sometimes broad definitions of health disparities
commonly used, a subcommittee convened by the
Secretarys Advisory Committee for Healthy People
2020 proposed an operational definition for use in
developing objectives and
targets, determining resource allocation priorities,
and assessing progress.
Based on that subcommittees work, we propose
that health disparities are
systematic, plausibly avoidable health differences adversely affecting socially
disadvantaged groups; they
may reflect social disadvantage, but causality need
not be established. This definition, grounded in ethical
and human rights principles, focuses on the subset
of health differences reflecting social injustice,
distinguishing health disparities from other health
differences also warranting
concerted attention, and
from health differences in
general.
We explain the definition,
its underlying concepts, the
challenges it addresses, and
the rationale for applying it to
United States public health
policy. (Am J Public Health.
2011;101:S149S155. doi:10.
2105/AJPH.2010.300062)

Paula A. Braveman, MD, MPH, Shiriki Kumanyika, PhD, MPH, Jonathan Fielding, MD, MPH, MA, MBA,
Thomas LaVeist, PhD, Luisa N. Borrell, DDS, PhD, Ron Manderscheid, PhD,
and Adewale Troutman, MD, MPH, MA

ONE OF 2 OVERARCHING
goals of Healthy People 20101 was
to eliminate health disparities
among different segments of the
population. A similar goal to
achieve health equity and eliminate health disparities was proposed by the Health and Human
Services Secretarys Advisory
Committee (SAC) for Healthy People 2020.2 Healthy People 2010
noted that health disparities include differences that occur by
gender, race or ethnicity, education or income, disability, living in
rural localities, or sexual orientation.1 However, the rationale for
identifying disparities in relation
to these particular population
groups was not articulated. The
National Institutes of Health defined health disparities as differences in the incidence, prevalence,
mortality, and burden of diseases
and other adverse health conditions that exist among specific
population groups in the United
States3,4; several other federal
agencies have similarly broad
definitions.5 The lack of explicit
criteria for identifying disparities
in Healthy People 20101 and the
relatively nonspecific definitions
of disparities used by federal
agencies3,4 leave considerable
room for ambiguity as to what
other groups might also be relevant.
Furthermore, there has been
controversy as to whether definitions of health disparities should
imply injustice or simply reflect
differences in health outcomes
that might apply to any United
States population segment.6---8 Different ethical, philosophical, legal,

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cultural, and technical perspectives may generate different definitions of health disparities or inequalities (the most comparable
term outside the United States).9---21
For example, in the United Kingdom, Whitehead defined health
inequalities as differences that are
unnecessary, avoidable, and unfair.21 This definition is widely
used internationally, where
health inequalities are assumed
to be socioeconomic differences
unless otherwise specified; in the
United States, however, health
disparities more often refer to
racial or ethnic differences.
Effective public policies require
clear and contextually relevant
operational definitions to support
the development of objectives and
specific targets, determine priorities for use of limited resources,
and assess progress. The need for
clear definitions is particularly
compelling given the lack of progress toward reducing racial/ethnic
and socioeconomic disparities in
medical care22 and health.23---25
Recognizing the practical implications of lack of clarity on this
critical issue, the SAC convened
a subcommittee to define health
disparity and health equity for
use in Healthy People 2020.2 The
subcommittee members, including
both SAC members and external
experts, wrote this paper to elaborate on the definitions and explain their rationale.2,26 These definitions (see the box on the next
page) and the rationale presented
are substantively consistent with
those adopted by the SAC and recently published in Healthy People
2020,2 but reflect some changes in

wording. Clarifying these concepts

will enable medical and public
health practitioners and leaders to
be more effective in reducing disparities in medical care and in
advocating for social policies (e.g.,
in child care, education, housing,
labor, and urban planning) that
can have major impacts on population health.27

UNDERLYING VALUES AND

PRINCIPLES
The concepts of health disparities and health equity are rooted
in deeply held American social
values and pragmatic considerations, as well as in internationally
recognized ethical and human
rights principles.9 Drawing on
ethical and human rights concepts,
key principles underlying the
concepts of health disparities and
health equity include the following:
All people should be valued
equally. This concept was articulated by Jones et al.28 as foundational to the concept of equity. Equal worth of all human
beings is at the core of the
human rights principle that all
human beings equally possess
certain rights.29,30
Health has a particular value for
individuals because it is essential
to an individuals well-being
and ability to participate fully in
the workforce and a democratic
society. Ill health means potential
suffering, disability, and/or loss
of life, threatens ones ability to
earn a living, and is an obstacle
to fully expressing ones views
and engaging in the political

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process. The Nobel Laureate

economist Amartya Sen31
viewed health as a fundamental
capability required to function
in society; similarly, ill health
can be a barrier to fully realizing ones human rights.
Because ill health can be an
obstacle to overcoming disadvantages, health disparities,
which further disadvantage socially disadvantaged groups,
seem particularly unfair.
Nondiscrimination and equality.
Every person should be able to
achieve his/her optimal health
status, without distinction based
on race or ethnic group, skin
color, religion, language, or nationality; socioeconomic resources or position; gender,
sexual orientation, or gender
identity; age; physical, mental,
or emotional disability or illness; geography; political or
other affiliation; or other characteristics that have been linked
historically to discrimination or
marginalization (exclusion from
social, economic, or political
opportunities). The groups represented by these characteristics
substantively agree with those
specified by the United Nations
Committee on Economic, Social
and Cultural Rights as vulnerable groups whose rights are at
particular risk of being unrealized, due to historic discrimination.32 This directly reflects the
human rights principles of
nondiscrimination and equality;
nondiscrimination includes
not only intentional but also
unintentional or de facto
discrimination, meaning discriminatory treatment embedded in structures and institutions, regardless of whether
there is conscious intent to discriminate.32,33 The late philosopher John Rawls19 advanced
the concept of a societys ethical

Health Disparities and Health Equity

Health disparities are health differences that adversely affect socially disadvantaged groups.
Health disparities are systematic, plausibly avoidable health differences according to race/ethnicity,
skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income,
wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography,
disability, illness, political or other affiliation; or other characteristics associated with discrimination
or marginalization. These categories reflect social advantage or disadvantage when they determine
an individuals or groups position in a social hierarchy (see the box on the next page).
Health disparities do not refer generically to all health differences, or even to all health differences
warranting focused attention. They are a specific subset of health differences of particular relevance
to social justice because they may arise from intentional or unintentional discrimination or
marginalization and, in any case, are likely to reinforce social disadvantage and vulnerability.
Disparities in health and its determinants are the metric for assessing health equity, the principle
underlying a commitment to reducing disparities in health and its determinants; health equity is
social justice in health.

obligation to maximize the wellbeing of those worst off. An

aversion to discrimination is
also firmly rooted in United
States policies, as exemplified by
the Civil Rights Act of 1964
prohibiting discrimination on
the basis of race, color, or national origin; the 1954 Brown
vs. Board of Education decision
desegregating schools; the Hill
Burton Act of 1946 prohibiting
hospitals receiving federal funds
from discriminating on the basis
of race, color, or creed; and the
Americans with Disabilities Acts
of 1990 and 2008 prohibiting
discrimination on the basis of
physical or mental disability.
Health is also of special importance for society because a nations prosperity depends on the
entire populations health.
Healthy workers are more productive and generate lower annual medical care costs.34---36
A healthier population has
more workers available for the
workforce. Health can facilitate
political participation, which
is essential for democracy.
Rights to health and to a standard
of living adequate for health. International human rights agreements, to which virtually all
countries are signatories, obligate

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governments to respect, protect,

fulfill, and promote all human
rights of all persons, including
the right to the highest attainable standard of health and the
right to a standard of living
adequate for health and wellbeing. Governments must demonstrate good faith in progressively removing obstacles to realizing these rights.29 The United
States signed but did not ratify
the International Covenant on
Economic, Social, and Cultural
Rights, which articulated the
right to health. Signing a treaty,
however, is considered an endorsement of its principles and
reflects acceptance of a good
faith commitment to honor its
contents. The right to health
(i.e., the right of everyone to the
enjoyment of the highest attainable standard of physical and
mental health37) is not to be
understood as a right to be healthy, because too many factors
beyond states control influence
health. Rather, it is the right to
a system of health protection
which provides equality of opportunity to enjoy the highest
attainable level of health. It includes the right to equal access to
cost-effective medical care as
well as to child care, education,

housing, environmental protection, and other factors that are

also crucial to health and wellbeing.38
Health differences adversely affecting socially disadvantaged
groups are particularly unacceptable because ill health can be
an obstacle to overcoming social
disadvantage. This consideration
resonates with common sense
notions of fairness, as well as
with ethical concepts of justice,
notably, the concept that need
should be a key determinant of
resource allocation for health,
and Rawls notion of the obligation to maximize the wellbeing of those worst off.39
Sen noted as a particularly serious . . . injustice . . . the lack
of opportunity that some may
have to achieve good health
because of inadequate social
arrangements. . . .40 Sen argued
that health is a prerequisite for
the capability to function normally in society.31 It is therefore
particularly unjust that those
who are socially disadvantaged
should also experience additional obstacles to opportunity
based on having worse health.
Ratifying human rights agreements obliges governments to
direct special effort toward

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equalizing the rights of vulnerable groups facing more obstacles to realizing their rights. A
nonexhaustive list of vulnerable
groups is specified in human
rights documents on nondiscrimination and equality.32,37,41,42
The resources needed to be
healthy (i.e., the determinants of
health, including living and
working conditions necessary for
health, as well as medical care)
should be distributed fairly. To
do so requires considering need
(along with capacity to benefit16
and efficiency17) rather than
ability to pay or influence in
society.17 This principle, along
with principles cited previously,
reflects the ethical notion of
distributive justice (a just distribution of resources needed for
health) and the human rights
principles of nondiscrimination
and equality, as well as the
right to a standard of living adequate for health. Investments
in medical care intended to
reduce disparities must be
weighed against other potentially more effective investments that address disparities
in other health determinants.38
Health equity is the value underlying a commitment to reduce and
ultimately eliminate health disparities. It is explicitly mentioned in the Healthy People
2020 2 objectives. Health equity means social justice with
respect to health and reflects the
ethical and human rights concerns articulated previously.
Health equity means striving to
equalize opportunities to be
healthy. In accord with the
other ethical principles of beneficence (doing good) and
nonmalfeasance (doing no
harm), equity requires concerted effort to achieve more
rapid improvements among

those who were worse off to

start, within an overall strategy
to improve everyones health.
Closing health gaps by worsening advantaged groups health is
not a way to achieve equity.
Reductions in health disparities
(by improving the health of the
socially disadvantaged) are the
metric by which progress toward health equity is measured.

although a causal link need not be

demonstrated. Differences among
groups in their levels of social
advantage or disadvantage, which
can be thought of as where
groups rank in social hierarchies,
are indicated by measures
reflecting the extent of wealth,
political or economic influence,
prestige, respect, or social acceptance of different population
groups.

HEALTH DISPARITIES:
DEFINITION AND
RATIONALE

Systematic But Not

Necessarily Causal Links With
Social Disadvantage

We briefly define health disparities and health equity (see the

box on the previous page), elaborating further and explaining in
this section. We also discuss social
disadvantage, a key concept for
understanding disparities and equity (see the box on this page).
Health disparities are systematic,
plausibly avoidable health differences adversely affecting socially
disadvantaged groups. They
may reflect social disadvantage,

As noted by Starfield,45 health

disparities are systematic, that is,
not isolated or exceptional findings. Health disparities are systematically linked with social disadvantage, and may reflect social
disadvantage, although a causal
link does not need to be demonstrated. Whether or not a causal
link exists, health disparities adversely affect groups who are already disadvantaged socially, putting them at further disadvantage
with respect to their health,

thereby making it potentially more

difficult to overcome social disadvantage. This reinforcement or
compounding of social disadvantage is what makes health disparities relevant to social justice even
when knowledge of their causation is lacking. It is important to
define health disparities without
requiring proof of causality, because there are important health
disparities for which the causes
have not been established, but
which deserve high priority based
on social justice concerns. For
example, the large Black---White
disparity in low birth weight
and premature birth strongly predicts disparities in infant mortality
and child development, and
likely in adult chronic disease.46
Although the causes of racial
disparity in birth outcomes are
not established,46 credible scientific
sources have identified biological mechanisms that plausibly
contribute to the disparities,46---50
which reflect phenomena shaped
by social contexts and thus are, at
least theoretically, avoidable.

Social Disadvantage
Health disparities and health equity cannot be defined without defining social disadvantage.
Social disadvantage refers to the unfavorable social, economic, or political conditions that some
groups of people systematically experience based on their relative position in social hierarchies.
It means restricted ability to participate fully in society and enjoy the benefits of progress. Social
disadvantage is reflected, for example, by low levels of wealth, income, education, or occupational
rank, or by less representation at high levels of political office. Criteria for social disadvantage can
be absolute (e.g., the federal poverty threshold in the United States is based on an estimate of the
income needed to obtain a defined set of basic necessities for a family of a given size)43 or relative
(e.g., poverty levels in a number of European countries are defined in relation to the median
income, e.g., less than 50% of the median income).44
Not all members of a disadvantaged group will necessarily be (uniformly) disadvantaged, and not all
socially disadvantaged groups will necessarily manifest measurable adverse health consequences.
The extent (whether in a single or multiple domains), depth (severity), and duration (e.g., across
multiple generations) of disadvantage matter. Social disadvantage is different from unavoidable
physical disadvantage due to, for example, an unavoidable physical disability. However, when
disabled persons are put at an unnecessary disadvantage in society due to lack of feasible
supports (e.g., accessible public buildings and transportation) or to discrimination against them in
hiring for work that they could perform, this would constitute social disadvantage,
reflecting discriminatory treatment, whether intentional or unintentional.

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Plausibly Avoidable
Differences in Health Given
Sufficient Political Will

and efficiently to reduce important

disparities.

Disadvantaged Groups Are

Not Necessarily Uniformly
Disadvantaged

It must be plausible, but not

necessarily proven, that policies
could reduce the disparities, including not only policies affecting
medical care but also social policies addressing important nonmedical determinants of health
and health disparities, such as a
decent standard of living; a level of
schooling permitting full social
participation, including participation in the workforce and political
activities; health-promoting living
and working conditions, including both social and physical environments; and respect and social
acceptance.23,51 This criterion
addresses the issue of avoidability,
which is central to Whiteheads
definition of health inequalities; it
strives for more specificity about
avoidability and to clarify the burden of proof regarding causality.21
Avoidability can be highly subjective. For example, one person
may believe that ill health caused
by poverty is avoidable; another,
however, may believe that both
poverty and ill health among the
poor are inevitable; hence, these
disparities are unavoidable. According to the proposed definition,
the criterion is whether the given
condition is theoretically avoidable,
based on current knowledge of
plausible causal pathways and biological mechanisms, and assuming
the existence of sufficient political
will. The more solid the knowledge, the more reasonable and
politically viable it will be to invest
resources in interventions; feasibility, costs, and potentially harmful unintended consequences
must be considered. Without firm
knowledge to guide specific interventions, pursuing health equity
would require supporting research
on how to intervene effectively

Worse Health Among Socially

Disadvantaged Groups

Internationally recognized human rights documents provide

guidance on which groups are
disadvantaged. Although health
disparities are systematic, a socially disadvantaged group will
not necessarily fare worse on all
health indicators, and might fare
better on some. For example, nonHispanic European American or
White (hereafter White) women
over age 40 have higher incidence
of breast cancer than non-Hispanic African American or Black
(hereafter Black) women,54 and
babies born to Hispanic immigrant
women often have more favorable
birth weights than those born to
non-Hispanic Whites.55 Neither of
these differencesalthough both
deserve public health attention
would be a health disparity by the
proposed definition. Regardless
of this type of exception in relation
to a health outcome, Whites as
a group are more socially advantaged than Blacks and Hispanics,
as data on income, wealth, education, occupations, and political
office have documented.56---58
Furthermore, on most health indicators, including breast cancer mortality, White women are healthier
than Black women.59 Similarly,
higher rates of a preventable
illness in 1 of 2 affluent geographic
regions would warrant public
health action, but not as a health
disparities concern.
The fact that not all members
of a disadvantaged group (e.g.,
Blacks) appear to be severely disadvantaged (e.g., we have a Black
United States President, and
some Blacks are highly educated,
in high professional positions,
and/or wealthy) does not contradict considering that group as
generally disadvantaged. The

Socially disadvantaged groups

are defined a priori, according to
criteria consistent with human
rights principles regarding nondiscrimination and equality.
Health disparities and equity
should be central considerations
for public policy relevant to
health, but they are not the only
considerations. Other legitimate
considerations include the magnitude of impact and proportion
of the population affected, as
well as efficiency in the use of
resources. If a more socially
advantaged group happens to
fare worse on a particular health
indicator, this may be a very important issue that public health
or other sectors should energetically address; but it is not part of
a health disparities agenda,
which focuses on improving the
health of socially disadvantaged
groups.

The Need to Reduce

Disparities in the
Determinants of Health
Health determinants include
not only medical care but also the
quality of the social and physical
conditions in which people live,
work, learn, and play.23,51,52
Evidence of disparities in health
determinants is thus relevant to
assessing disparities in health.
Society will generally be more
motivated to address health differences that appear to result
from modifiable circumstances
over which individuals may have
little control21,53; for example,
the quality of local schools, exposure to pollution or crime,
or absence of stores selling nutritious food in ones neighborhood.

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issue is whether the group has been

on the whole more disadvantaged
than Whites. Ample evidence has
documented a longstanding pattern
of less wealth,60,61 lower incomes,
lower educational attainment, and
under-representation in positions
of high occupational rank56 and
financial and political power62
among Blacks as a group compared with Whites. Despite an end
to legal racial segregation decades
ago, racial residential segregation
persists and with it, de facto educational segregation, condemning
many Black children to poor
quality schools. This reduces their
chances of obtaining good jobs
with adequate income as adults,
perpetuating social disadvantage
across generations.63,64
Similarly, although many
United States women are affluent
and some now hold high professional and political offices, as
a group, they are more likely
than men to be poor,65 to earn
less at a given educational level,66
and to be underrepresented in
high political office.67 Human
rights documents on nondiscrimination explicitly name women as
a vulnerable group warranting
special protection from discrimination. Patterns suggesting clinically unjustified underreceipt of
certain cardiac treatments by
women compared with men68
would reflect a gender disparity
in a determinant of health
(medical care, in this instance).
Shorter life expectancy among
men in general, if likely avoidable, would clearly be an issue of
public health importance based
on the magnitude of potential
population impact. However,
men as a group have more
wealth, influence, and prestige, so
this difference would not be
a social injustice and, therefore,
not a health disparity or equity
issue.

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Health Disparities as the

Metric to Assess Progress
Toward Health Equity
The stated criteria permit the
assessment of measurable progress toward greater health equity.
Systematic associations with social
disadvantage can be identified by
observing a repeated pattern of
correlations between measures of
social disadvantage and a health
outcome. Social advantage and
disadvantage can be measured by
comparing populations on factors
such as levels of wealth, income,
educational attainment, or occupational rank, for example (see the
box on page S151). Demonstrating
that a given disparity is plausibly
avoidable and can be reduced by
policies requires being able to describe, at least in general terms, 1
or more potential causal pathways
that are consistent with current
scientific knowledge; it does not
require definitively establishing
either the causation of the disparity or proving the effectiveness of
existing interventions to reduce
it. Guidelines for measuring health
disparities are available.9,69---73
Increasingly, the term health
inequity21,74,75the opposite of
health equityis being used instead of health disparity to capture explicitly the moral dimension
and differentiate health differences
thought to reflect injustice from
health differences in general. Examples of health differences that
would not be considered health
disparities according to our definitions (see the box on page S150)
include: elderly adults generally
having worse health than nonelderly adults; skiers being at higher
risk of long-bone fractures than
nonskiers; and men not having
obstetric problems, whereas
women do. Both health disparity
and health inequity have their
place in the public health lexicon.

Health inequity, however, is a

forceful term tending to imply
a strong judgment about causality,
which may be difficult to support in
many cases that nevertheless deserve attention as health disparities
(i.e., health differences adversely
affecting socially disadvantaged
groups) regardless of their causation. As with health equity, measuring health inequity relies on
health disparities as the metric.

Health Disparity: Not Just

a Health Difference
Interpreting the term health
disparities as any health differences among any population
group, as has been done by some
federal agencies, encompasses the
entire domain of epidemiology,
which is the study of the distribution of diseases and risk factors
across different populations. We
have argued that the term health
disparities should be used advisedly, in the spirit of the movement
for social justice from which the
term emerged, to refer to a particular subset of differences in health
that meet well-specified criteria
of specific relevance to social justice. The definitions proposed here
were designed to clarify the concepts of health disparities and
health equity in ways that could
stand up to rigorous conceptual
scrutiny as a basis for guiding
policy and practice and ensuring
accountability, which requires
clear criteria for measurement.9,69,70 To achieve the desired rigor, the full versions of the
proposed definitions are complex
and technical and will not be suitable for all audiences; for many
audiences, it may be most appropriate to define health disparities
simply as worse health among
socially disadvantaged groups
and then elaborate as necessary,
drawing on the more comprehensive form of the definitions.

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Limitations
These definitions do not provide numerical cutoffs for determining disadvantage. Nor do they
remove completely the need to
exercise judgment based on values
that are likely to vary across individuals and societies. It is
difficult to imagine reasonable
definitions of these concepts,
however, that would provide rigid
cutoffs, would completely preclude the exercise of judgment,
and would leave no room for
contention. The proposed definitions do not clarify whether the
reference group for making equity/disparities comparisons
should be the most advantaged
group in ones country or in the
world; using ones country as the
reference point may ignore the
better health achieved by advantaged populations in other parts of
the world.

Challenges Addressed
The definitions address major
challenges, such as identifying the
social groups to be compared and
specifying the general criteria for
appropriate reference groups for
these comparisons.18 These challenges have arisen when considering health disparity or equity
issues, with serious implications
for resource allocation. These
definitions remove the need to
establish the causality and avoidability of each health difference for
it to qualify as a health disparity
worthy of special attention. To address the difficult issue of causality,
our definitions acknowledge that
a health disparity may or may not
arise from social disadvantage, but
it must adversely affect members of
socially disadvantaged groups; this
can be assessed using epidemiologic
data revealing repeated and pervasive associations between health
indicators and measures of social

advantage. The causes need not be

known definitively, if it is biologically plausible that the difference
could be reduced by policies.
These definitions also ground the
concepts of health disparities and
health equity in internationally
recognized principles from the
fields of ethics and human rights,
giving them universality and durability. Although human rights
are often honored more in the
breach than in the observance,
they are a powerful resource in
that they represent a global consensus on values. This consensus
can be an important point of reference in national and local debates on policies and practice in
the United States. It would be
nave to think that achieving consensus on a definition would obviate the need for constant vigilance to ensure that the agenda for
research and action on health disparities remains on track and true
to the essence of the definition;
however, having a clear definition
is crucial.

The Issue is Justice

Could this approachputting
health disparities within the
broader context of ethics and human rightsjeopardize the limited
resources allocated to specifically
address racial/ethnic disparities,
by spreading these resources more
thinly among other disadvantaged
groups? Would broadening the
definition make the concept too
abstract and therefore less compelling to the public and policymakers? We concluded that the
struggle for racial justice, in which
efforts to eliminate racial/ethnic
disparities in health are crucial,
has far more to gain than to lose
from making these principles explicit. The relevant ethical and
human rights principles support
prioritizing attention to those facing the greatest obstacles, and

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ample evidence has documented

the multiple and often crushing
obstacles faced by members of
disadvantaged racial/ethnic
groups in the United States, in
some cases for centuries. These
principles can protect initiatives
to address racial/ethnic as well as
other disparities in health from
a range of potential challenges
that constitute real threats.
Previous official approaches to
defining health disparities in the
United States have avoided being
explicit about values and principles, perhaps for fear of stirring
political opposition, because of
genuine differences in values or
because of the prevailing ethos
that enjoins researchers to avoid
the realm of values that might
compromise the integrity of their
science. Scientists, like all others,
should be guided by ethical and
human rights values. The first
decade of the 21st century has
ended with little if any evidence
of progress toward eliminating
health disparities by race or socioeconomic status.22 It is time to
be explicit that the heart of a
commitment to addressing health
disparities is a commitment to
achieving a more just society. j

About the Authors

Paula A. Braveman is with the University
of California, San Francisco. Shiriki
Kumanyika is with University of
Pennsylvania School of Medicine,
Philadelphia. Jonathan Fielding is with the
University of California, Los Angeles,
School of Public Health. Thomas LaVeist is
with Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD. Luisa N.
Borrell is with Lehman College, City
University of New York, New York. Ron
Manderscheid is with the National
Association of County Behavioral Health
and Developmental Disability Directors,
Washington, DC. Adewale Troutman is
with the Louisville Metro Department of
Public Health and Wellness, Louisville, KY.
Correspondence should be sent to Paula A.
Braveman, MD, MPH, Director/Professor,
Center on Social Disparities in Health,
University of California, San Francisco,

3333 California St., Suite 365, San Francisco,

CA 94118 (e-mail: Braveman@fcm.ucsf.edu).
Reprints can be ordered at http://www.ajph.
org by clicking the Reprints/Eprints link.
This article was accepted November 1,
2010.

Contributors
All the authors participated conceptually
in developing the recommendations to
the Secretarys Advisory Committee
(SAC) on Healthy People 2020, which
were the starting point for this article, and
all authors contributed ideas, reviewed
drafts, and made comments that shaped
this article in important ways. P. A.
Braveman conceived the initial idea for
the article, wrote initial drafts, and wrote
most revisions for coauthors review,
based on their comments. S. Kumanyika
also played a major role in writing the text
and a lead role in responding to external
reviewer comments. J. Fielding, T. LaVeist,
L. N. Borrell, R. Manderscheid, and
A. Troutman also contributed conceptually
and participated in substantive revisions
throughout the process.

Acknowledgments
We wish to thank Karen Simpkins, MLS,
and Colleen J. Barclay, MPH, for their
assistance with research. Written permission has been obtained from all persons
named here. The authors take full responsibility for the contents of this paper
as individuals. This article is not an official
report from the SAC or from the subcommittee to the SAC.
Note. The research presented here
neither has been published nor is being
considered for publication elsewhere,
and all research for this manuscript was
conducted in accord with prevailing
ethical principles. We have no affiliations with or involvement in any organization or entity with a direct financial
interest in the subject matter or materials
discussed in this manuscript. None of the
authors received compensation for this
work. The authors take full responsibility for the material.

Human Participant Protection

No institutional review board approval
was required.

References
1. US Department of Health and
Human Services. Office of Disease Prevention and Health Promotion. Healthy
People 2010: Understanding and improving health. 2nd ed. Washington,
DC: US Government Printing Office;
2000.
2. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People

S154 | Environmental Justice | Peer Reviewed | Braveman et al.

2020, November 2010. Available at:

http://www.healthypeople.gov/2020/
about/disparitiesAbout.aspx. Accessed
April 8, 2011.
3. National Institute of Arthritis and
Musculoskeletal and Skin Diseases. Strategic plan for reducing health disparities.
Available at: http://www.niams.nih.gov/
About_Us/Mission_and_Purpose/strat_
plan_hd.asp. Accessed September 7, 2010.
4. National Cancer Institute. Health
disparities defined. Available at: http://
crchd.cancer.gov/disparities/defined.html.
Accessed September 7, 2010.
5. Carter-Pokras O. What is a health
disparity? Public Health Rep. 2002;117:
426---434.
6. Jones CM. The moral problem of
health disparities. Am J Public Health.
2010;100(suppl 1):S47---S51.
7. Bloche MG. Health care disparities--science, politics, and race. N Engl J Med.
2004;350(15):1568---1570.
8. Steinbrook R. Disparities in health
care---from politics to policy. N Engl J Med.
2004;350(15):1486---1488.
9. Braveman P. Health disparities and
health equity: concepts and measurement.
Annu Rev Public Health. 2006;27:167--194.
10. Daniels N, Kennedy B, Kawach I.
Justice is good for our health. Boston
Review 2000 February/March 25(1):
4---19.
11. Wagstaff A, van Doorslaer E. Equity
in health care finance and delivery. In:
Culyer S, Newhouse J, eds. Handbook of
Health Economics. Amsterdam: North
Holland; 2000.
12. Sen A. The Idea of Justice. Cambridge,
MA: Harvard University Press; 2009.
13. Braveman P, Gruskin S. Poverty,
equity, human rights and health. Bull World
Health Organ. 2003;81(7):539---545.

19. Rawls J. A Theory of Justice. Cambridge: Belknap/Harvard University

Press; 1971.
20. Ruger JP. Health and social justice.
Lancet. 2004;364(9439):1075---1080.
21. Whitehead M. The concepts and
principles of equity and health. Health
Promot Int. 1991;6(3):217---228.
22. Voelker R. Decades of work to
reduce disparities in health care produce
limited success. JAMA. 2008;299(12):
1411---1413.
23. Braveman P, Egerter S. Overcoming
Obstacles to Health: Report from the Robert
Wood Johnson Foundation to the Commission to Build a Healthier America. Princeton, NJ: Robert Wood Johnson Foundation; 2008.
24. Singh GK, Kogan MD. Widening
socioeconomic disparities in US childhood mortality, 1969-2000. Am J
Public Health. 2007;97(9):1658--1665.
25. Singh GK, Siahpush M. Widening
socioeconomic inequalities in US life expectancy, 1980-2000. Int J Epidemiol.
2006;35(4):969---979.
26. Fielding J, Kumanyika SK. Recommendations for the concepts and form of
Healthy People 2020. Am J Prev Med.
2009;37(3):255---257.
27. Beyond Health Care. New Directions
to a Healthier America. Recommendations
from the Robert Wood Johnson Foundation
Commission to Build a Healthier America.
Washington, DC: Robert Wood Johnson
Foundation Commission to Build a
Healthier America; 2009.
28. Jones CP, Hatch A, Troutman A.
Fostering a social justice approach to
health. In: Braithwaite RL, Taylor SE,
Treadwell HM, eds. Health Issues in the
Black Community. 3rd ed. Hoboken, NJ:
John Wiley & Sons; 2009.

14. Braveman P, Gruskin S. Defining

equity in health. J Epidemiol Community
Health. 2003;57(4):254---258.

29. Gruskin S, Mills EJ, Tarantola D.

History, principles, and practice of health
and human rights. Lancet. 2007;370
(9585):449---455.

15. Braveman P, Starfield B, Geiger HJ.

World Health Report 2000: how it
removes equity from the agenda for
public health monitoring and policy. BMJ.
2001;323(7314):678---681.

30. Yamin AE. Shades of dignity: exploring the demands of equality in applying human rights frameworks to
health. Health Hum Rights. 2009;11(2):
1---18.

16. Culyer AJ. Equitysome theory and

its policy implications. J Med Ethics. 2001;
27(4):275---283.

31. Sen A. Development as Freedom. New

York: Random House; 1999.

17. Daniels N, Bryant J, Castano RA,

et al. Benchmarks of fairness for health
care reform: a policy tool for developing
countries. Bull World Health Organ.
2000;78(6):740---750.
18. Braveman P, Krieger N, Lynch J.
Health inequalities and social inequalities
in health. Bull World Health Organ.
2000;78(2):232---235.

32. UN Committee on Economic, Social

and Cultural Rights (CESCR), General
comment No. 20: Non-discrimination in
economic, social and cultural rights (art. 2,
para. 2, of the International Covenant on
Economic, Social and Cultural Rights), 2
July 2009, E/C.12/GC/20. Available at:
http://www.unhcr.org/refworld/publisher,
CESCR,GENERAL,4a60961f2,0.html.
Accessed April 7, 2011.

American Journal of Public Health | Supplement 1, 2011, Vol 101, No. S1

TOWARDS ENVIRONMENTAL JUSTICE AND HEALTH EQUITY

33. Jones CP. Levels of racism: a theoretic framework and a gardeners tale. Am
J Public Health. 2000;90(8):1212---1215.

eurofound.europa.eu/ewco/surveyreports/
EU0703019D/EU0703019D_3.htm.
Accessed September 7, 2010.

34. LaVeist TA, Gaskin DJ, Richard P.

The Economic Burden of Health Inequalities in the United States. Washington, DC:
Joint Center for Political and Economic
Studies; 2009.

45. Starfield B. Improving equity in

health: a research agenda. Int J Health
Serv. 2001;31(3):545---566.

35. Lerner D, Allaire SH, Reisine ST.

Work disability resulting from chronic
health conditions. J Occup Environ Med.
2005;47(3):253---264.
36. Vijan S, Hayward RA, Langa KM.
The impact of diabetes on workforce
participation: results from a national
household sample. Health Serv Res. 2004;
39(6p1):1653---1670.
37. International Covenant on Economic. Social and Cultural Rights
(ICESCR), G.A. Res. 2200A (XXI), Art. 12.
1966. Available at http://www2.ohchr.
org/english/law/cescr.htm. Accessed
April 7, 2011.
38. UN Economic and Social Council.
Committee on Economic, Social and
Cultural Rights. The Right to the Highest
Attainable Standard of Health. General
Comment No. 14. (E/C.12/2000/4),
2000.
39. Daniels N. Democratic equality:
Rawls complex egalitarianism. In: Freeman S, ed. The Cambridge Companion to
Rawls. Cambridge, UK: Cambridge University Press; 2003:241---276.
40. Sen A. Why health equity? Health
Econ. 2002;11(8):659---666.
41. U.N. Economic and Social Council.
Committee on Social and Cultural Rights,
43rd Session. The Limburg Principles on
the Implementation of the International
Covenant on Economic,. 4th Comment
(E/CN 17), April 1987.
42. International Commission of Jurists
(ICJ). Maastricht Guidelines on Violations
of Economic, Social and Cultural Rights,
26 January 1997. Available at: http://
www1.umn.edu/humanrts/instree/
Maastrichtguidelines_.html. Accessed
April 7, 2011.
43. US Department of Health and Human Services. Poverty Guidelines, Research, and Measurement. Available at
http://aspe.hhs.gov/poverty. Accessed
September 7, 2010.
44. European Working Conditions Observatory. Income poverty in the European Union. Available at http://www.

46. Institute of Medicine, Committee

on Understanding Premature Birth and
Assuring Healthy Outcomes, Board on
Health Sciences Policy. Preterm Birth:
Causes, Consequences, and Prevention.
Washington, DC: The National Academies Press; 2007.
47. Wadhwa PD, Culhane JF, Rauh V,
et al. Stress, infection and preterm birth:
a biobehavioural perspective. Paediatr Perinat Epidemiol. 2001;15(suppl 2):17---29.
48. Dominguez TP, Dunkel-Schetter C,
Glynn LM, et al. Racial differences in birth
outcomes: the role of general, pregnancy,
and racism stress. Health Psychol. 2008;
27(2):194---203.
49. Hobel CJ, Goldstein A, Barrett ES.
Psychosocial stress and pregnancy outcome. Clin Obstet Gynecol. 2008;51(2):
333---348.
50. Lu MC, Halfon N. Racial and ethnic
disparities in birth outcomes: a life-course
perspective. Matern Child Health J. 2003;
7(1):13---30.
51. Commission on Social Determinants
of Health. Closing the Gap in a Generation:
Health Equity Through Action on the Social
Determinants of Health. Final Report of the
Commission on Social Determinants of
Health. Geneva, Switzerland: World
Health Organization; 2008.
52. Wilkinson R, Marmot M, eds. Social
Determinants of Health. The Solid Facts.
2nd ed. Geneva, Switzerland: World
Health Organization; 2003.
53. Hebert PL, Sisk JE, Howell EA.
When does a difference become a disparity? Conceptualizing racial and ethnic
disparities in health. Health Aff (Millwood).
2008;27(2):374---382.
54. Centers for Disease Control and
Prevention. Breast cancer rates by race
and ethnicity. Available at: http://www.
cdc.gov/cancer/breast/statistics/race.
htm. Accessed November 30, 2009.
55. Centers for Disease Control and
Prevention. State-specific trends in U.S.
live births to women born outside the 50
states and the District of Columbia
United States, 1990 and 2000. MMWR

Supplement 1, 2011, Vol 101, No. S1 | American Journal of Public Health

Morb Mortal Wkly Rep. 2002;51(48):

1091---1095.
56. US Census Bureau. The American
CommunityBlacks: 2004. American
Community Survey Reports. Available
at: http://www.census.gov/prod/2007
pubs/acs-04.pdf. Accessed December 11,
2009.
57. US Census Bureau. The American
CommunityHispanics: 2004. American
Community Survey Reports. Available
at: http://www.census.gov/prod/2007
pubs/acs-03.pdf. Accessed December 11,
2009.
58. LaVeist TA. Disentangling race and
socioeconomic status: a key to understanding
health inequalities. J Urban Health. 2005;
82(2, Suppl. 3):iii26---iii34.
59. Henry J. Kaiser Family Foundation.
Putting womens health care disparities on
the map: examining racial and ethnic
disparities at the state level. June 2009.
Available at: http://www.kff.org/
minorityhealth/upload/7886.pdf.
Accessed January 11, 2010.
60. Bond Huie SA, Krueger PM, Rogers
RG, Hummer RA. Wealth, race, and mortality. Soc Sci Q. 2003;84(3):667---684.
61. Braveman PA, Cubbin C, Egerter S,
et al. Socioeconomic status in health research: one size does not fit all. JAMA.
2005;294(22):2879---2888.
62. Joint Center for Political and Economic Studies. African Americans in
statewide elective office. Available at:
http://www.jointcenter.org/index.php/
current_research_and_policy_activities/
political_participation/black_elected_
officials_roster_introduction_and_
overview/african_americans_in_statewide_
elective_office. Accessed November 30,
2009.
63. Laveist TA. Segregation, poverty,
and empowerment: health consequences
for African Americans. Milbank Q. 1993;
71(1):41---64.

66. Bishaw A, Semega J. Income, Earnings, and Poverty Data From the 2007
American Community Survey. U.S. Census
Bureau, American Community Survey Reports. Washington, DC: U.S. Government
Printing Office; 2008.
67. Center for American Women and
Politics. Rutgers University. Women in
elective office 2009. Fact sheet. Available
at: http://www.cawp.rutgers.edu/fast_
facts/levels_of_office/documents/elective.
pdf. Accessed November 30, 2009.
68. Agency for Healthcare Research and
Quality. National Healthcare Disparities
Reports. Data Tables Appendix. Available
at: http://www.ahrq.gov/qual/nhdr09/
Chap4c.htm#women. Accessed September 7, 2010.
69. Braveman PA, Egerter SA, Cubbin
C, Marchi KS. An approach to studying
social disparities in health and health care.
Am J Public Health. 2004;94(12):
2139---2148.
70. Harper S, Lynch J. Methods for
Measuring Cancer Disparities: Using
Data Relevant to Healthy People 2010
Cancer-Related Objectives. Bethesda, MD:
National Cancer Institute; 2005.
71. Braveman P. Monitoring equity in
health and health care: a conceptual
framework. J Health Popul Nutr 2003;
21(3):181---192.
72. Mackenbach JP, Kunst AE, Cavelaars
AE, et al. Socioeconomic inequalities in
morbidity and mortality in western
Europe. The EU Working Group on
Socioeconomic Inequalities in Health.
Lancet. 1997;349(9066):1655---1659.
73. Wagstaff A, Van Doorslaer E. Measuring inequalities in health in the presence of multiple-category morbidity
indicators. Health Econ. 1994;3(4):
281---289.

64. Williams DR, Collins C. Racial residential segregation: a fundamental cause

of racial disparities in health. Public Health
Rep. 2001;116(5):404---416.

74. National Association of City and

County Health Officials. Health equity
and social justice. Available at: http://
www.naccho.org/topics/justice. Accessed
December 10, 2009.

65. Spraggins RE. We the people:

Women and men in the United States. US
Census Bureau. Census 2000 Special
Reports. January 2005. Available at:
http://www.census.gov/prod/2005
pubs/censr-20.pdf. Accessed November
30, 2009.

75. Prevention Institute and Health

Policy Institute. Reducing inequities in
health and safety through prevention.
January 23, 2009. Available at: http://
www.preventioninstitute.org/documents/
HealthEquityMemo_012309.pdf. Accessed December 10, 2009.

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